Endobronchial Ultrasound Referral
Patient Name:
NHI:
DOB:
Address:
Phone:
Referrer:
Date of Referral:
Reason for Referral: (please tick):
Diagnosis and Staging of suspected cancer
Staging of confirmed cancer
Mediastinal adenopathy ?cause
Others, please specify
Date and location of recent CT/PET CT:
Medical History: (including smoking history)
Functional (ECOG) Status:
Is the patient currently on any anticoagulants/antiplatelet agents?
Yes
No
If so, please state which anticoagulants eg Aspirin, Warfarin, Clopidogrel, Dabigatran
Is the patient on Metformin?
Yes
No
Blood results:
Date
INR
Hb
Platelets
Has the patient agreed to the procedure?
Yes
No
Any other comments:

Please ensure CT is sent electronically to Waikato DHB

Please attach a clinic letter or discharge summary

Please fax to:
Dr Janice Wong, Respiratory Physician, Waikato Hospital, Fax (07) 839 8770

Alternatively e-mail to: chestconf@waikatodhb.health.nz
WAIKATO HOSPITAL
Pembroke St, Private Bag 3200, Hamilton. Phone 07 839 8899 Fax: 07 839 8770